MEDICAL TREATMENT

Addiction Treatment Catching Up With Groundbreaking Brain And Genetic Research

Seven.

That's how many attempts it took Joseph Bryant to kick lifetime
addictions that began with alcohol when he was just 10, followed by
heavy marijuana use in his teens, and topped by a $700-a-day heroin
habit in his 20s.

After he served prison sentences for car theft and drug peddling, and
as he took up residence in abandoned houses at the age of 27, he
realized he had to change his life, or he would find himself, as he
put it, "in jail for the rest of my life or dying on the streets of Baltimore."

Bryant's seventh - and last - try to overcome his addictions in 2004
couldn't have been better timed.

Even as he bounced in and out of a string of ineffective treatment
centers, innovative research and changing attitudes about drug
addiction, treatment and recovery were starting to take hold.

New and effective medications now suppress drug cravings. Hospitals
and treatment centers are making stronger efforts to prevent people
with addictions from falling through the cracks as they are passed
between institutions. And physicians, hospitals and private clinics
have learned that treatment means not only medical attention but
setting the stage for a successful reentry into a challenging life
without drugs and alcohol, with social services, housing and job training.

The strongest treatment programs have always offered a smorgasbord of
services under one roof or connected critical lifelines for their
clients, but the push now across the country is fueled by
groundbreaking brain research in the late 1990s that indicates that
addiction isn't driven by weak character, loose morals or lax discipline.

While downing those first few drinks or pills may be a choice, 20
studies conducted over as many years indicate that, from there,
genetics may take over for up to half of addicted Americans. In 1987,
Brookhaven National Laboratory became the first research institution
to use imaging to study brain changes in the aging, obese or
addicted. Led by Nora Volkow, now the director of the National
Institute on Drug Abuse, researchers at the Upton, N.Y., lab
documented alterations in the brain linked to drug abuse, alcoholism
or other impulse behaviors that suggested a genetic predisposition to
addiction.

Subsequent research, increasingly sophisticated, has made even
stronger connections.

The discovery has led to a growing sense that a connect-the-dots
approach is needed at every turn to help people like Bryant, who has
clearly benefited from his first comprehensive treatment plan - he's
been clean since that summer two years ago.

"It's a good time to be addicted," said Thomas McLellan, the founder
and executive director of the Treatment Research Institute in
Philadelphia, a research think tank that attempts to influence
clinical practice and public policy through scientific and real-world
studies. "The treatment is beginning to catch up with research. This
will save a ton of money and, more importantly, lives."

At the same time, the medical, addiction and treatment communities
are paying attention to what's called "the continuum of care," a buzz
phrase meaning addiction treatment and recovery - as well as the
training of health-care professionals - that promises seamless
experiences for patients who work with a variety of specialists on
the way to their new lives.

Still, McLellan and others see an area of medicine that still
languishes. The ties between doctors, hospitals and treatment centers
are still disconnected in many communities. Tired stigmas and
misconceptions about addiction hinder vital partnerships between
institutions, and make it harder for patients to talk to their
doctors about their problem.

Health-care providers also make it exceedingly difficult for people
with addictions to get help; insurers severely limit coverage,
leading to what amounts to a class divide in treatment. Affluent
Americans can dip into their own pockets or tap into company benefits
for services that can easily exceed $20,000 for treatment and ongoing
recovery, while middle-class and poor Americans struggle to find
financial help, or go without.

Addiction also gets relatively low priority in the medical community,
starting with training. Though efforts to improve medical school
curriculum are growing, a new generation of doctors still doesn't get
enough exposure to diagnosing and treating addiction. Dr. Jennifer
Smith, a physician at John Stroger Hospital of Cook County in Chicago
and a professor at Rush Medical College, remembers receiving two
hours of instruction in addiction during her four years of medical
training in the early 1980s. The scenario has only slightly improved, she says.

"We're not at a tipping point yet," Smith said. "But we're getting there."

That's important, because physicians, researchers say, are key in
making the link between addiction and chronic disease, a connection
that historically hasn't been strong. While treatment and recovery
centers, pharmaceutical companies, scientists and researchers all
liken addiction to heart disease, cancer and diabetes, medical
doctors aren't applying the latest data to their patients.

"As a country, we took alcoholism out of the medical milieu," Smith
said. "For many years, addiction didn't belong to doctors. This is
changing with time."

If addicts today stand a much stronger chance of getting and staying
sober and clean, science is largely the reason. While environment and
stress play a role, the studies indicate strong genetic and
biological links passed through addicted parents make offspring more
susceptible to addiction.

If your parents or siblings are hooked on alcohol or drugs, these
studies concluded, you have a 50 percent chance of addiction; some
studies put the likelihood of addiction as high as 70 percent. What's
more, once addicted, the part of the brain linked to the
pleasure-reward system heightens cravings for the drug, so trying to
stop addiction without treatment is near impossible.

Armed with the science, pharmaceutical companies have responded with
three different drugs to combat the cerebral cravings: buprenorphine,
acamprosate and naltrexone. The drugs, available only this decade
under a variety of commercial brands, are designed to curb or even
eliminate cravings and minimize the side effects of withdrawal for
both alcohol and specific drugs, like opiates, marijuana and cocaine.

The drugs alone don't ensure successful recovery; they need to be
part of a larger strategy, doctors say. But the new medications,
taken over a period of days, months or years, have offered new hope.

For Bryant, one new medication provided the antidote to a string of
failed recovery efforts, when, he says, previous treatment centers
"didn't pay attention to details. There was no one on one to help you
find out why you were on drugs. Therapy was not available."

The new medicines weren't available to him, either, so he tried
slowly weaning himself off drugs. During one such attempt while he
was in prison, the pain of withdrawal was so great that he ran
head-first into the brick wall of his cell to knock himself unconscious.

On his last try, Bryant turned to an uncle in New York who enrolled
him in a Phoenix House treatment facility in Brooklyn, N.Y. What
Bryant found there is everything researchers and social scientists
recommend in a drug rehabilitation and recovery program - beginning
with buprenorphine.

The small orange pill, quickly dissolved under his tongue, eliminated
Bryant's cravings. The intense physical pain common to withdrawal was
so minimal that Bryant found he could sleep through the night. "I
could eat," he said. "The hot and cold sweats, the chills - the drug
minimized all of that."

Within his first week of treatment, Bryant was off buprenorphine and
transferred from his detoxification room to a bed under the same
roof, a logistical godsend at a critical time in treatment. Following
his previous detox experiences, he had been sent to recovery centers
often miles away; sometimes they had available beds, but more often
Bryant had to wait two or three days. The interruption proved costly.
That's when Bryant invariably found himself back on drugs.

On the one occasion that he could immediately move from detox to a
bed, he was told after 28 days that he was being discharged because
another client needed the bed - and because his funds had run out.
"Whether you are ready or not, you have to go. That's one of the
messed-up things about recovery. People look at it as a business."

And treatment and recovery is a lucrative business. In 2001, the last
year for which statistics are available, $18 billion was spent on
substance abuse treatment, up from $11 billion in 1991, according to
a study by the federal Substance Abuse & Mental Health Services
Administration. In that same 10-year period, public sources like
Medicaid shouldered the brunt of payment.

Bryant, for example, had to use Medicaid to pay for his treatment and
recovery at Phoenix House, the nation's largest nonprofit addiction
treatment and recovery organization, which charges $19,000 a year.
Drug-free for 18 months and in the last stages of his recovery
program, Bryant still lives there, leasing a room for $15 a week
until he saves enough money from his job as a carpenter to find his
own place. Housing assistance is key in its recovery program, Phoenix
House officials say, because the low-cost shelter allows people in
recovery a solid shot at long-term stability as they piece together
their lives.

After spending much of his life living on the edge, Bryant approaches
his life these days with simplicity - and sobriety. "I take my life
one day at a time," he says.

New attitudes about taking responsibility, more support from
psychologists and psychiatrists, assistance from job counselors and
vocational training programs have ushered in a fresh mindset in the
last decade at places like the Audie Murphy Hospital, part of the
sprawling South Texas Veterans Health Care System in San Antonio.

"Before, we treated anyone for any reason," said Dr. Ursula
Sanderson, chief of the residential rehabilitation program. Maybe
their habit had become too expensive. Or they were homeless with an
addiction. Whatever the reason, Sanderson said, veterans with
addictions showed up routinely at the clinic, appearing so often that
the staff considered them "family" and welcomed them warmly.

"We would admit anyone as long as we had a bed," Sanderson said. "We
had a large revolving door."

Gone are the days when people with addictions could simply walk into
the clinic and check themselves in. Non-emergency room visitors are
screened for possible substance abuse, and if there is no immediate
health risk, addicted veterans are referred to a psychiatric unit or
the health center's detoxification unit.

During the typical monthlong stay, days are structured, crammed with
meetings with doctors, psychologists or psychiatrists, nurses and job
counselors and, when the time is right, job training and job
placement. The revamped treatment and recovery program is more
collaborative, more comprehensive.

"For one, the veteran was not participating," said Sanderson of the
old days. Now, she said, after developing a written statement of his
life, he meets with a psychiatrist, a nurse, a psychologist, a social
worker, a recreational therapist and even a chaplain, all in the same
room, to design a lifestyle plan that will take him through recovery
and reintroduction to society. "We establish pretty clearly where
they are going to go," Sanderson said, "and how they are to support
themselves."

Carlos Canales, 48, in recovery for a decade, has benefited from the
hospital's heightened sophistication. During his first stay in the
mid-1990s, he remembers a strong sense that people were simply
"warehoused." Today, Canales said, "the caliber of care and the
caliber of understanding of what it takes to care for people in this
situation is greater."

The Air Force veteran and former teacher credits the services with
helping him redirect a life that was waylaid for more than two
decades by addictions of every sort.

He first began drinking beer at his San Antonio high school to "fit
in" and to overcome his low self-esteem. By the time he graduated in
1976, he was drinking heavily. He joined the Air Force and added
recreational drugs. Every chance he had, he either drank or did drugs
- - sometimes both.

"I wandered around in a self-medicated state for 22 years," he said.
"I did coke, heroin, pot, alcohol, whatever was accessible."

In his late 30s, he knew was in trouble. He checked himself in to the
veterans' hospital, where he detoxed and began using the hospital's
growing array of services. Key to his recovery was the support from
the Veterans' Administration - "Otherwise," Canales said, "I would
have ended up in a state hospital or prison."

He still attends weekly support meetings at the hospital and the
staff greets him by his first name, even though he hasn't seen anyone
there medically for four or five years.

"That's pretty outstanding," he says, of the staff's attention to
details. "I'm in good shape now, thanks to the hospital."

The years of abuse and failed treatment took their toll, however.
Canales has terminal liver disease.